Though cardiac transplantation for advanced heart disease patients remains definitive therapy for patients with advanced heart failure, it is challenged by inadequate donor supply, causing durable mechanical circulatory support to slowly become a new primary standard. Selecting appropriate patients for MCS involves meeting a number of prespecifications as is required in evaluation for cardiac transplant candidacy. As technology evolves to bring forth more durable smaller devices, selection criteria for appropriate MCS recipients will likely expand to encompass a broader, less sick population. The “Holy Grail” for MCS will be a focus on clinical recovery and explantation of devices rather than the currently more narrowly defined indications of bridge to transplantation or lifetime device therapy.